Elise Geithner
[box]Hypothesis[/box]
My research investigates the disparity in respiratory health of Indigenous versus non-Indigenous Australians. It explores the long cultural history of smoking in Aboriginal communities, the history of displacement and a lack of access to health information, care, and support for quitting as possible explanations for the disparity. Results indicate that the most important steps to ameliorating the health of Indigenous Australians (IAs) are understanding the root causes of adverse conditions, the IA’s perception of their health and well-being, and the individual differences that shape the health of an individual, a community, and a population. The best way to close this gap is to develop a culturally sensitive intervention that is catered to the unique needs of each community of IAs. A successful intervention will target village elders, children, and health workers, each of whom play a critical role in increasing smoking cessation rates of a community. It will incorporate traditional health practices of this population, rather than imposing a Western biomedical treatment model, which could be alienating and ineffective.

[box]Introduction[/box]
Previous research has shown that the most robust factor in uptake and continuation of smoking is social context. For disadvantaged groups such as IAs, the challenges of unemployment, high stress, and lack of access to education and healthcare make individuals more likely to smoke and less likely to quit.1 IAs have also experienced cultural fragmentation and loss of identity, contributing to their poor mental health. This is correlated with high rates of substance addiction. Smoking must be addressed in the Indigenous context as a “collective social practice as opposed to an individual lifestyle behavior”.1 In order for a health intervention to be successful, it must address culture as a motivating force behind patterns of tobacco use and obstacles of quitting, and it must obtain community buy-in and ownership of the proposed behavior changes. Because the issue of indigenous health is caused and maintained by the complex interaction of environmental and genetic factors, there is no simple solution.

In this paper, a survey will be conducted of current literature on the smoking culture of IAs and the benefits and limitations of current anti-smoking interventions. The data indicates that an effective, culturally sensitive solution involves recognition of the complex web of fundamental causes of the issue, and rigorous effort is required on behalf of Indigenous communities and outside agencies.

[box]Methods[/box]
Data for this project was gathered from interviews and observation at La Perouse Medical Center and Red Fern Aboriginal Health Services in Sydney, Australia, as well as bibliographic sources and online videos.

[box]Results[/box]

I. Origins of the smoking problem

In the 1700s, Macassan fishermen from Indonesia first introduced tobacco to the IAs, who incorporated the smoking pipes into their ceremonies.1 The ritual of passing a tobacco pipe gained popularity, and smoking rituals were passed down through generations alongside oral traditions of creation and coming-of-age ceremonies. In 1788, when Europeans arrived in Australia, white settlers paid Aboriginal laborers in tobacco, and IAs began to use it recreationally rather than strictly ceremoniously.1 Indigenous communities saw their smoking rates skyrocket, especially because the activity was seen as a family practice. Furthermore, up until the 1960s, many Aboriginal doctors viewed smoking as an antidote to stress and either smoked with their patients or in their presence.2 Social pressures, both implicit and explicit from friends and family who smoke, have maintained the behavior in communities to this day.1

Today, tobacco remains rooted in the traditional IA kinship system. Sharing tobacco is a way of giving and receiving honors and strengthening kinship ties. Abstaining from smoking rituals may be seen as a rejection of the tribe and can lead to isolation. Children who grow up in a community where individuals who chose to quit smoking are isolated often feel that maintenance of smoking behavior is the only way to remain part of the mob.

II. The land-health connection
“You lose your land, you lose your soul, you lose your life.” -Vic Simms3

An Indigenous person’s relationship to the land is crucial for his/her communal identity, individual identity, and sense of wellbeing. Without land, an Aboriginal person’s sense of belonging and purpose is diminished, and this could lead to substance use, including smoking. Dispossession by white settlers has resulted in unstable family and community environments, negatively impacting mental health. IAs are hospitalized for mental and behavioral disorders at twice the rate of their non-Indigenous peers.4 As part of the Stolen Generation, many adult survivors of childhood separation experience major psychological issues.5 Many IAs who feel stressed by unemployment or from mental illness in the aftermath of forcible relocation by the government have turned to smoking as a short-term antidote. Tobacco increases alertness and suppresses one’s appetite; these are cited by Indigenous smokers as justifications for smoking. When asked why they smoke, IAs in New South Whales responded, it “tastes good, makes me look deadly, keeps me awake, calms me down”.6

Cultural fragmentation and associated identity confusion are the result of colonization around the world. The history of Indigenous and non-Indigenous relations in North America and New Zealand parallels that of Australia. In a comparison of the health discrepancies between Indigenous and non-
Indigenous peoples in North America, New Zealand, and Australia, the greatest disparity between Indigenous and non-Indigenous life expectancy is in Australia; 56 years for males, 63 years for females.7 The Australian Bureau of Statistics makes a conservative estimate of a gap of 9.7 and 11.5 years for females and males, respectively, between IAs and non-Indigenous Australians, while some have suggested a gap as high as 20 years.8,9

Of all Indigenous Australians and Torres Strait Islanders over the age of 15, 47% are current daily smokers.10 Surprisingly, 52% of pregnant Aboriginal women smoke, compared with 17% of women in the overall population.10 IA babies are twice as likely as their non-Indigenous counterparts to have low birth weights, and therefore prematurely developed lungs, which are more prone to developing infections and asthma, when exposed to tobacco smoke.9 The infant mortality rate for IAs is 2.5 times the total population rate.9 By giving up smoking, moms will lower their children’s respiratory health risks.
The smoking trends in the IA population are widely understood to be contributing to poor physical and psychosocial health and longevity. In 2006, the Australian Bureau of Statistics found that 66% of children ages 0-14 lived in a house with at least one regular smoker.10 Because they grow up around family members who smoke, it is no surprise that children and teenagers make up the majority of all new smokers. Through education about household smoking health risks, we can reduce smoking-induced morbidity and mortality.

III. IA Reception to Interventions
Despite numerous government interventions, Indigenous smoking rates remain stable, and these interventions have received mixed reviews from the Indigenous community. The graphic images of TV ads and pamphlets led Vic Simms age 65 of the Bidjigal tribe to quit; “I would have never known about my severe heart conditions, if it weren’t for the government’s anti-smoking campaigns” which describe the horrific consequences of smoking. Greg Ingram, the AMS Red Fern mental health director, believes that government interventions make the IA community dependent on the government, rather than encouraging autonomy (16 November 2011). Ingram discussed the negative impact of historical displacement and segregation on Aboriginal people’s social and emotional wellbeing. Over time, Red Fern has seen an increase in education levels, but current government policy is “making things go backwards.”

Future anti-smoking campaigns should promote the positive aspects of quitting, rather than over-emphasize the negative consequences of smoking. Psychology research has shown that framing conditions positively rather than negatively helps the brain integrate information more effectively. Diabetes Australia NSW used this technique in their pamphlet’s section titled “Why quitting smoking is good for you and your mob.” By appealing to the pathos of their audience, the organization was able to deliver scientific information in an accessible, rather than overly technical or alienating way.

Other challenges in the IA community are the widespread notions of egalitarianism and general resistance to Western interference. People who quit “can be derided by other Aborigines as trying to be like ‘grubs’ or ‘white fella.’”11 In close-knit Aboriginal communities, “leveling procedures” such as group pressure, shaming, and gossip, reinforce the group psyche, impeding individuals’ quitting efforts. Another challenge to treating adults with smoking addictions is the ideal of personal autonomy “and an associated antipathy to being told what to do”11. Western health interventions often conflict with traditional Indigenous health beliefs such as the idea that “premature death and sudden illness” is the result of a “supernatural cause,” even if an individual was a heavy user of alcohol or drugs.11
The IA community is generating their own response to the smoking issue. In the past five years, there has been an explosion in the number of anti-smoking videos on YouTube, which are catered specifically to IAs. For example, “Kick the Habit”2012 was made by IA schoolgirls singing in their native language about taking responsibility for one’s own health and quitting.

IV. Contemporary IA Morbidity and Mortality
Many IAs are complacent about tobacco because it is such a widespread problem. Future health efforts must increase awareness of “tobacco as a health priority,” one that need not be separate from efforts to ameliorate alcohol abuse, domestic violence, and poverty.13 Traditionally, the government health organizations have addressed one of these issues at a time, but holistic approaches may actually be more effective. One key to ameliorating poor health is offering and ensuring access to high quality services. In the past, IAs have not had easy access to adequate healthcare. Ensuring that IAs have equitable access to health professionals is an issue of social justice. Through cooperation between government, non-government agencies, and community leaders, Australia has the potential to improve the health of its Indigenous population.

It was difficult to compare the success of current interventions against each other, because they measured different outcomes: % increase in individuals quitting, % increase in confidence of health workers to offer cessation advice, % decrease in individuals smoking. However, the effectiveness of several interventions could be graphically compared, revealing that the chemical options (Nicotine Replacement Therapy, Buproprion, and Varenicline) yielded the most dramatic quitting results. These findings should not be taken to advocate widespread use of NRT, but rather to help individuals gain an understanding of its effectiveness in some cases. The best way to tackle the smoking problem in its entirety is through community partnerships with health organizations.

[box]Discussion[/box]

I. Comparing Existing Interventions
There are many approaches that seek to close the gap in smoking between Indigenous and non-Indigenous Australians, and there has yet to be a widely successful intervention. It is unlikely that a “one size fits all” approach will work, given the varying needs of each Indigenous community. “Things don’t change overnight because the government says, ‘let’s stop smoking.’ It’s a mindset change and a societal change,” says Dr. Tom Calma, an elder from the Kungarakan and Iwaidja tribal groups, whose traditional lands are in the Northern Territory.14 “From a public health perspective, the best solution is for people not to start smoking cigarettes – smoking prevention,”

explains Lupton, a sociologist of health and illness.15 Whether an intervention falls into the prevention or the treatment category, it must address smoking at two levels: the habit and the addiction.15 Interventions range from public health education campaigns (“I Quit Because” 2011) to specific training of community health workers (SmokeCheck 2009) and distribution of pharmaceutical aids. There has also been health education for children and teens, family-centered interventions, quitting support groups, and national media campaigns (National Tobacco Campaign 1997-present). Another angle is implementing legal controls on tobacco advertising, packaging, taxation, and pricing. A holistic solution is needed for this problem.

II. Using the Addiction Treatment Model
Another way to address the use of alcohol, tobacco, and other drugs in Indigenous populations is “culture as a form of healing”.11 This idea has spread from native Canadians and American Indians to Australia through cultural diffusion. “It is now accepted that treatment and rehabilitation for native peoples should be culturally appropriate” and may even involve going back to the roots of the culture.11 Native Americans and Canadians have been incorporating traditional and spiritual practices into addiction treatment programs and some say “embracing their culture assists them in achieving sobriety”.11

Many Indigenous peoples feel that “cultural wholeness can serve as a preventative, or even curing agent in drug and alcohol abuse,” and this method can be applied to smoking cessation programs.11 The rationale for the use of tradition in addictions intervention “rests upon the Indigenous interpretation of the etiology of drug and alcohol abuse” – their status as a colonized and dispossessed population.11 Prior to the arrival of white settlers, the traditional smoking ceremony was designed to “cleanse and protect the strength of the spirit.”16 This is seen as separate from the contemporary use of tobacco, in the form of cigarettes laden with over 4,000 chemicals.17 However, there is also evidence for substance abuse in Aboriginal communities “whose social organization remains relatively intact, and who have retained intimate contact with their land”.11 Thus, there is no perfect formula for causation of the issue, but we can look at correlations, risk factors, and protective factors.

III. Suggestions for Further Research
Social scientists should continue investigating how to improve IA health. It is important to assemble a board of representatives from each Aboriginal community, or tap into existing National Aboriginal Health organizations, so that anti-smoking materials can be translated into Indigenous languages. Funding for the proposed programs is a crucial component to success. It’s important to further investigate the rural/urban trends of smoking and health, to see if these evolve over time. Currently, health status is worse in rural Aboriginal communities than in urban ones. However, as Aboriginal people are displaced from their lands, or move into cities seeking jobs and better opportunities, will they face new health challenges, or will they be able to take advantage of better access to healthcare? Will they experience declines in mental health because they are leaving their traditional lands and losing their connection with their cultural history? Will benefits of city life, including education and employment opportunities, outweigh these potential risks? The ability of the scientific and public health communities to cooperate with IAs will become a crucial piece in tackling the disproportionately high rates of smoking in that population.

[box]Conclusion[/box]
Combating the smoking problem in IA communities will require continued dedication of health organizations and Indigenous community leaders. Health workers cannot undo the damage of colonization to the roots of Aboriginal Australians, but they can move forward towards improving health outcomes. Hopefully, one day, the community will work to close the gap between Indigenous and non-Indigenous peoples in Australia and around the world.

Elise Geithner is a junior majoring in Human Biology. She was born in Tokyo and grew up in DC and NY. She dreams of being a pediatric and adolescent psychiatrist when she grows up. She’s particularly interested in the mental health issues of adolescent girls and is on a lifelong mission to destigmatize mental illness, therapy, and bike helmet wearing. In her free time, she enjoys babysitting, cooking, hiking, surfing, running, doing art projects, and teaching yoga to kids and adults.

1. Johnston, Vanessa, and David P. Thomas. “Smoking Behaviours in a Remote Australian Indigenous Community: The Influence of Family and Other Factors.” Social Science and Medicine 67 (2008): 1708-716. ScienceDirect. Web. 23 Sept. 2011. .
2. Casey, Bill. “Australian Studies.” University of Queensland. 21-26 Nov. 2011. Lectures.
3. Simms, Vic. “The Indigenous Communities of La Perouse and Red Fern.” Sydney, Australia. 15, 16 Nov. 2011. Lecture.
4. Hunter, Ernest. “Disadvantage and Discontent: A Review of Issues Relevant to the Mental Health of Rural and Remote Indigenous Australians.” Australian Journal of Rural Health 15 (2007): 88-93. The Centre for Rural and Remote Mental Health, Cairns, Queensland, Australia, Feb. 2007. Web. 9 Nov. 2011. .
5. Corporal, Stephen. “Indigenous Health.” Personal interview. 25 Nov. 2011.
6. SMOKERS: It’s Deadly to Know. North Sydney, NSW: NSW Department of Health: Tobacco and Health Branch, 2005. Print.
7. Bramley, Dale, Paul Hebert, Rod Jackson, and Mark Chassin. “Indigenous Disparities in Disease-specific Mortality, a Cross-country Comparison: New Zealand, Australia, Canada, and the United States.” The New Zealand Medical Journal 117.1207 (2004): 1-16. New Zealand Medical Journal. 17 Dec. 2004. Web. 27 Nov. 2011. .
8. “DEMOGRAPHIC, SOCIAL AND ECONOMIC CHARACTERISTICS: LIFE EXPECTANCY.” Australian Bureau of Statistics. 16 Feb. 2011. Web. 25 Nov. 2011. .
9. Ring, Ian T., and Ngaire Brown. “Indigenous Health: Chronically Inadequate Responses to Damning Statistics.” Medical Journal of Australia 177 (2002): 629-31. Medical Journal of Australia. Web. 23 Sept. 2011. .
10. Ivers, Rowena. Australia Government Institute of Health and Welfare. Institute of Family Studies. Anti-tobacco Programs for Aboriginal and Torres Strait Islander People. Resource Sheet Number 4 ed. Closing the Gap Clearinghouse, Jan. 2011. Web. 21 Oct. 2011. .
11. Brady, Maggie. “Culture in Treatment, Culture as Treatment. A Critical Appraisal of Developments in Addictions Programs for Indigenous North Americans and Australians.” Social Science and Medicine 41.11 (1995): 1487-496. PubMed. US National Library of Medicine. Web. 27 Nov. 2011. .
12. Kick the Habit.mov. Yirrkala Homelands School. Online video advertisement. YouTube. 22 June 2010. Web. 3 Dec. 2011. .
13. “Interventions Targeting Aboriginal Peoples and Torres Straits Islanders.” Tobacco in Australia. Web. 20 Oct. 2011. .
14. “Smoking and Pregnancy Program.” Rural Health Education Foundation. Australian Government Department of Health and Aging, 22 Apr. 2008. Web. 20 Oct. 2011. .
15. Lupton, Gillian M., and Jakob M. Najman. Sociology of Health and Illness: Australian Readings. Macmillan Education AU, 1995. Print.
16. Smoking and Diabetes (fact sheet). NSW: Diabetes Australia-NSW. Print.
17. “Cigarettes Are Full of Poisons.” Quit Because You Can. 2007. Web. 3 Dec. 2011. .